Transcript Preoperative Testing: What, When, and If

Pre-operative Testing:
What is Really Needed?
Robert H. Lohr, MD FACP
Mayo School of Continuous Professional Development
South Dakota ACP Meeting
September 12, 2013
Deadwood, SD
©2011 MFMER | 3127551-1
Disclosures
• No financial disclosures
• No discussion of “off label” use of drugs
Objectives
• To understand the rationale for evidence based
preoperative testing
• To understand when preoperative testing is not
indicated…Most of the time!
Today’s Outline
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Background
Cases
Discussion/rationale
Back to our cases
Questions
Is Preoperative Testing a Problem
• Yes, and a big one
• It wastes valuable resources
• It exposes patients to needless blood work and
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procedures
It can creat anxiety for patients
It is costly…$30 billion/year (1987 $)
It is still a problemsurgeons>anesthesiologists>preoperative directors
• Katz, Anesth Analg 2011
• Roizen, Anesthesiol Clin North Am 1987
Why Should we Test?
• To identify or verify a condition which could affect
anesthetic care
• To help formulate or modify anesthetic care of the
patient
• Can the identified risk be mitigated?
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Cardiac
Pulmonary
Drugs
Bleeding, clotting, and bridging
DM
• Other (liver, kidneys, endocrine)
Anesthesiology 2012 (ASA Practice Advisory for Preanesthesia
Evaluation)
How Do You Decide?
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My last case (that went south…)
What my chief resident told me to do
EBM
Guidelines…which ones?
Hospital policies…who develops?
Case 1
• You are asked to see a 43 year old male for a
preoperative medical evaluation. He is
scheduled for an inguinal hernia repair next
week
• His past medical history is notable only for
obesity (BMI 32) and an uncomplicated ORIF of
a tib-fib fracture at age 14
• He has never used tobacco and has 1-2 oz of
EtOH/week
Case 1
• He does construction work and can easily
exceed > 4 METS of activity
• He takes only a men’s multivitamin daily
• His exam is noteworthy for his weight and an
easily reducible R inguinal hernia.
Case 1
• For preoperative testing you order:
• A) An ECG and CBC
• B) An ECG and creatinine
• C) A CBC and creatinine
• D) A CBC and INR
• E) No tests
Case 2
• You are asked to see a 78 year old female for a
preoperative medical evaluation. She is
scheduled for an elective R TKA tomorrow
• Her past medical history is noteworthy for
hypertension, hyperlipidemia, obesity, DJD,
and coronary artery disease for which she
received 2 drug eluting stents 4 years ago.
Case 2
• She has had a hysterectomy and carpel tunnel
repair in the past without complication
• Her medications include lisinopril/HCTZ,
simvastatin, metoprolol, aspirin
• She is limited in her activity due to her knee,
but was able to do >4METS of activity within
the past several months
Case 2
• Her exam reveals a BP of 143/80, P 60, BMI of
37, and a moderate effusion on the R knee.
Cardiovascular and pulmonary exams are
normal
• You have an ECG available (NSR, non-specific
lateral ST changes) from 3 months ago
• You have no other laboratory data available
Case 2
• Preoperatively you order:
• A) An ECG, electrolytes, creatinine
• B) Electrolytes, creatinine
• C) An ECG, electrolytes, creatinine, and INR
• D) Electrolytes, creatinine, ECG, and a
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dobutamine stress Echo
E) No testing
Case 3
• You are asked to see a 58 year old male for a
preoperative medical evaluation. He is
scheduled for a R TSA next week
• His past medical history is significant for
hepatitis C but no history of cirrhosis. He had
an inguinal hernia repaired as a child without
complication. He has had no recent follow up
regarding his liver.
• Medications include a multivitamin
Case 3
• His functional capacity is excellent, exceeding 4
METS
• His exam is normal except for a decreased
range of motion of his R shoulder
Case 3
• Preoperatively you order:
• A) An ECG, electrolytes, creatinine
• B) Electrolytes, LFT, creatinine
• C) LFT, INR, creatinine
• D) INR and aPTT
• E) No studies
Case 4
• You are asked to do a pre-operative evaluation
for a 23 year old female college basketball
point guard for repair of a torn L ACL
• She reports herself to be in excellent health, no
prior surgery, having irregular menstrual
periods felt secondary to her level of physical
activity
• She is taking no medicines and her physical
exam is normal except for her L knee
Case 4: You order pre-operatively
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CBC
EKG
PT/PTT
Pregnancy testing
No testing
Should we test?
Preoperative testing: Should we do
anything?
• Narr et al.
• Randomized 1044 patients who had NO
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preoperative testing, age 0-95, median 21
Deaths: 0.0%
17 intraoperative lab tests; 3 abnormal
No testing done intraoperatively or
postoperatively changed management
• Narr. Mayo Clin Proc 1997;72:505-509
Should we Test?
• Preoperative testing should be dictated by the
patient’s clinical condition and abnormal
findings on history or exam
• Preoperative testing is NOT INDICATED unless
there is a specific reason to perform the test
and the result will change management, or
mitigate perioperative risk
The Preoperative ECG
• No prospective, randomized clinical controlled
trials
• No good, prospective outcome data for or against
• Lots of retrospective reviews, case series, cohort
studies
• Lots of complicated, conflicting consensus
statements regarding pre-operative ECG
• Main cardiovascular risk assessment guidelines
use ECG to risk stratify
Pre-op ECG
• The prevalence of an abnormal ECG increases
with age with up to 75% of people older than 75
having an abnormal ECG
• There is evidence suggesting poorer outcomes in
patients with abnormal ECGs
• RR 4.5 (3.3-6.0) of death
• However, absolute risk reduction only 0.5%
with low and intermediate risk surgery
Noordzij. Am J Cardiol 97(7): 1103-1106
ECGs?
• Conflicting recommendations amongst
consensus organizations
• ACC/AHA
• ASA
• ICSI
• ESC/ESA
ECGs?
ECG YES
• CV symptoms/signs
• Known stable cardiac disease
• Risk factors and intermediate or high risk
surgery
• RCRI ≥ 1
• CAD equivalent
ECGs?
ECG NO
• Low risk surgery and low risk patient
• Cataract surgery
ECG MAYBE
• Low risk patient and intermediate risk surgery
• Risk factors and low risk surgery
Coagulation Studies?
• Coagulation studies only as indicated by H&P
• What about high risk surgery e.g. neurosurgery:
“Patient history was as predictive as lab testing for
all outcomes (and had) higher sensitivity”
Seicean, J Neurosurg 2012
• Known h/o bleeding disorder or previous
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bleeding complications
On current anticoagulation
H&P suggests bleeding or coagulation
problems
CBC?
• H&P findings suggestive of abnormality
• Known cytopenia
• Recent chemo
• h/o bleeding
• pallor
• ? Anticipated large surgical blood loss
• ? Situation where even mild anemia could be
significant
Electrolytes, Creatinine?
• Lytes, creatinine
• Patients on diuretics
• Patients with known renal failure
• ? Patients on digoxin
CXR?
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Frequent abnormalities --- 10-23.1%
Rarely influence management --- < 0.1-3%
Predictable from H&P
Who follows up on the abnormality? --- source
for missed opportunity, “falling through the
cracks”
• Qaseen A et al. Ann Intern Med. 2006; 144: 575-580
Albumin?
• Powerful predictor of perioperative
complications
• Pulmonary complications increased
• Infectious complications increased
• Wound healing issues
• In some settings the strongest predictor of
morbidity and mortality
Gibbs J et al. Arch Surg. 1999;134:36-42
Albumin?
• Consider serum albumin
• If modifiable risk factor present
• AND it would change your perioperative
management
Glucose?
• No good evidence for or against
• Will it change my management?
• Would I delay surgery if it was high?
• Would my perioperative management change?
LFTs?
• Play it again Sam…only if there is suspicion of
liver disease on the basis of history, exam, or
previous liver function abnormality
• www.nature.com/clinicalpractice/gasthep
• If there are indications to perform LFTs, include
INR, bilirubin, creatinine in order to calculate
MELD score which predicts post operative
mortality due to liver disease
• Gastroenterology 2007;132:1261-1269
Pregnancy Testing
• 2056 women of child bearing age tested before
elective ambulatory surgery
• 7 had + pregnancy testing (0.3%)
• Cost of pregnancy discovered: $2879
• All cancelled their surgery
• 2558 women of child bearing age tested before
elective orthopaedic surgery
• 5 had + pregnancy testing (0.2%)
• Cost of discovered pregnancy: $3273
Anesthesiology 1995
Anesth Analg 2008
Pregnancy Testing
• “…the literature is inadequate to inform patients
or physicians on whether anesthesia causes
harmful effects on early pregnancy. Pregnancy
testing may be offered to female patients of
childbearing age and for whom the result would
alter the patient’s management.”
Anesthesia 2012 (ASA Practice Advisory for Preanesthesia
Evaluation)
Case 1
• You are asked to see a 43 year old male for a
preoperative medical evaluation. He is
scheduled for an inguinal hernia repair next
week
• His past medical history is notable only for
obesity (BMI 32) and an uncomplicated ORIF of
a tib-fib fracture at age 14
• He has never used tobacco and has 1-2 oz of
EtOH/week
Case 1
• He does construction work and can easily
exceed > 4 METS of activity
• He takes only a mens multivitamin daily
• His exam is note worthy for his weight and an
easily reducible R inguinal hernia.
Case 1
• For preoperative testing you order:
• A) An ECG and CBC
• B) An ECG and creatinine
• C) A CBC and creatinine
• D) A CBC and INR
• E) No tests
Case 2
• You are asked to see a 78 year old female for a
preoperative medical evaluation. She is
scheduled for an elective R TKA tomorrow
• Her past medical history is note worthy for
hypertension, hyperlipidemia, obesity, DJD,
and coronary artery disease for which she
received 2 drug eluting stents 4 years ago.
Case 2
• She has had a hysterectomy and carpel tunnel
repair in the past without complication
• Her medications include lisinopril/HCTZ,
simvastatin, metoprolol, aspirin
• She is limited in her activity due to her knee,
but was able to do >4METS of activity within
the past several months
Case 2
• Her exam reveals a BP of 143/80, P 60, BME
of 37, and a moderate effusion on the R knee.
Cardiovascular and pulmonary exams are
normal
• You have an ECG available (NSR, non-specific
lateral ST changes) from 3 months ago
• You have no other laboratory data available
Case 2
• Preoperatively you order:
• A) An ECG, electrolytes, creatinine
• B) Electrolytes, creatinine
• C) An ECG, electrolytes, creatinine, and INR
• D) Electrolytes, creatine, and a dobutamine
•
stress Echo
E) No testing
Case 3
• You are asked to see a 58 year old male for a
preoperative medical evaluation. He is
scheduled for a R TSA next week
• His past medical history is significant for
hepatitis C but no history of cirrhosis. He had
an inguinal hernia repaired as a child without
complication. He has had no recent follow up
regarding his liver.
• Medications include a multivitamin
Case 3
• His functional capacity is excellent, exceeding 4
METS
• His exam is normal except for a decreased
range of motion of his R shoulder
Case 3
• Preoperatively you order:
• A) An ECG, electrolytes, creatinine
• B) Electrolytes, LFT, creatinine
• C) LFT, INR, creatinine
• D) INR and aPTT
• E) No studies
Case 4
• You are asked to do a pre-operative evaluation
for a 23 year old female basketball guard for
repair of a torn L ACL
• She reports herself to be in excellent health, no
prior surgery, having irregular menstrual
periods felt secondary to her level of physical
activity
• She is taking no medicines and her physical
exam is normal except for her L knee
Case 4: You order pre-operatively
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•
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•
•
CBC
EKG
PT/PTT
Pregnancy testing
No testing
Take Home Points
• ALL PREOPERATIVE TESTING SHOULD BE
DICATATAED BY YOUR HISTORY AND EXAM
Thank You
• QUESTIONS